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Info


A. History

  1. Significant non-ophthalmologic history
  2. Severe life-threatining injuries may need to be addressed first
  3. Details of accident
    1. Loss consciousness
    2. Blunt versus penetrating trauma
    3. Time elapsed since injury
    4. Last oral intake (if surgery repair considered)
    5. Type of agent if chemical
  4. Always check visual acuity
  5. Visual status before accident helpful (including previous treatments)
  6. Nearly all injuries involving eyes should be evaluated early on by an ophthalmologist
  7. High risk in young boys > young girls

B. Four Causes of Traumatic Visual Loss

  1. Refractive Error - check with pinhole test
  2. Media Opacities - subluxed lens, corneal scar, vitreous hemorrhage
  3. Macular Disease - choroidal rupture, retinal detachment, commotio (retinal concussion)
  4. Optic Nerve Disease - traumatic optic neuropathy, optic nerve avulsion

C. Foreign Bodies

  1. Diagnosis
    1. Thorough search, including under the eye lids
    2. Always flip upper lid
    3. Fluorescein with blue light to reveal subtle corneal abrasions
  2. Removal of Object from Cornea
    1. Internist may try quick pass with anesthetized Q-tip
    2. If fails to dislodge, refer to ophthalmologist
    3. Metallic - foreign bodies need be removed or will leave irritating rust ring
    4. Burr or 30 gauge needle helpful, but ophthalmologist should perform removal
  3. Removal of Object from Posterior Segment
    1. Immediate referral to ophthalmologist
    2. Surgical evaluation needed, often with ensuing urgent/emergent surgery
  4. Post-operative management
    1. Antibiotic until epithelium heals
    2. If grinding or drilling metal, dilated fundoscopy to check for foreign body
    3. Artificial tears as needed

D. Chemical Injuries

  1. Acid not as damaging as base (alkali coagulates proteins more quickly)
  2. Irrigation with 0.9% normal saline is choice (any neutral fluid) until pH between 6.8-7.2
  3. Do not attempt to neutralize; irrigation only is recommended
  4. Ominous signs requiring prompt ophthalmology referral
    1. Perilimbal whitening rather than injection suggests ischemia
    2. Corneal clouding
    3. Anterior chamber inflammatory reaction
    4. Second or third degree lid skin burns
    5. Increased intraocular pressure
  5. Ophthalmologist will treat with various agents:
    1. Topical steroids
    2. Collagenase inhibitors (such as topical tetracycline)
    3. Vigorous surface lubrication
  6. Corneal Transplants
    1. Epithelial stem-cell transplants may be effective with severe corneal damage [2]
    2. Expansion of autologous limbal epithelial (stem) cells in vitro is now possible
    3. These expanded cells (on an amniotic membrane) can be transplanted to damaged corneas
    4. Substantial improvement in vision occurred in 6 of 6 patients undergoing these autologous transplants [3]
    5. If limbal epithelial stem cells are damaged, engineered cell sheets with autologous oral mucosal epithelium have demonstrated excellent success [4]

E. Ruptured Globe

  1. Sharp objects less damaging than blunt
  2. Blunt objects cause acute pressure increase
    1. This may lead to corneoscleral rupture
    2. Rupture occurs at limbus or near insertions of extraocular muscles
  3. Referral for ophthalmology evaluation
    1. Suspicion of penetrating or perforating injury (see below)
    2. Patient not 20/20 (with no other adequate explanation)
    3. Patient where a specific diagnosis not made to explain discomfort
    4. Patient who did not or could not have a complete eye exam due to lid swelling
  4. Suspicion of Penetrating / Perforating Injury
    1. Suspected intraocular foreign body - iris perforation, air in eye
    2. Bullous subconjunctival hemorrhage
    3. Deep anterior chamber
    4. Low intraocular pressure
    5. Vitreous hemorrhage

F. Anterior Segment Trauma

  1. Visual prognosis usually better than posterior injury
  2. Structures can be replaced fairly effectively with surgery
    1. Corneal replacement - penetrating keratoplasty (transplants)
    2. Lens - intraocular lens
  3. Hyphema
    1. Bleeding in anterior chamber
    2. Can lead to glaucoma or corneal blood staining
    3. Especially ominous in sickle cell patients: increased chance of optic nerve ischemia
    4. Long term incience of glaucoma increased if angle recession occurs

G. Posterior Segment Trauma

  1. Very serious injury
  2. Foreign Body
    1. Metals - copper and iron very inflammatory
    2. Bee-bee
    3. Wood - can lead to bacterial or fungal endophthalmitis
    4. Usually require vitrectomy to remove
  3. Concern is Retinal Detachment
  4. Commotio Retinae
    1. Retinal concussion
    2. Blunt nontearing injury
    3. Whitening of retina with decreased vision
    4. Usually resolves to baseline acuity over several weeks
  5. Choroidal Rupture
    1. Seen in blunt trauma
    2. Curvilinear breaks with intra- and subretinal hemorrhage
    3. Late visual loss secondary to choroidal neovascularization leading to exudative detachment and disciform scarring
  6. Child Abuse
    1. "Shaken Baby Syndrome"
    2. In context of subdural / subarachnoid hemorrhage with long bone fracture
    3. Ophthalmologist plays significant role in diagnosing typical intraretinal hemorrhages that are rarely caused by other types of purported trauma (falling out of crib, etc.)

H. Orbital "Blow Out" Fracture

  1. Usually medial or inferior orbital wall
  2. Signs / Symptoms
    1. Binocular diplopia with extraocular motility limitation
    2. Hypesthesia in Cranial Nerve V(2) distribution
    3. Palpable step off of orbital rim
    4. Enophthalmos - eye sunken in
  3. Refer to ophthalmologist for evaluation of muscle entrapment in fracture
    1. Thin cut (1.5mm) axial and coronial CT scan aide in evaluation
    2. MRI will not be helpful
    3. Surgical repair may be required

I. Traumatic Optic Neuropathy

  1. Often due to indirect injury to head
  2. Signs / Symptoms
    1. Decreased vision
    2. Visual field defect
    3. Afferent pupillary defect
    4. Decreased color vision
  3. CT scan to evaluate perimural hemorrhage or compression of optic canal (bone fragments)
  4. Treatment
    1. Intravenous glucocorticoids (as for spinal injury)
    2. Surgical Decompression of optic canal

References

  1. Simon JW and Kaw P. 2001. Am Fam Phys. 64(4):623 abstract
  2. Tsubota K, Satake Y, Kaido M, et al. 1999. NEJM. 340(22):1697 abstract
  3. Tsai RJF, Li LM, Chen JK. 2000. NEJM. 343(2):86 abstract
  4. Nishida K, Yamato M, Hayashida Y, et al. 2004. NEJM. 351(12):1187 abstract